abraham rice, md medical director, foster care clinic contra costa regional medical center domestic...
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Abraham Rice, MDMedical Director, Foster Care Clinic
Contra Costa Regional Medical Center
Domestic Violence in Pediatrics
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Take home messagesDV is a pediatric issueDV / CEV is prevalentCEV are at high risk many bad outcomesWe should screen for, diagnose and treat
violence and it’s predictable sequelae
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Problem of Children Exposed to Violence
Between 7 – 15 million children witness DV per year.
CEV more likely experience emotional and
behavioral problems
Greatly at risk for abuse and poverty CEV are a medical issue
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Definition of Domestic ViolenceDV is “a pattern of coercive behaviors that
may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation and intimidation. These behaviors are perpetrated by someone who is or was involved in an intimate relationship with the victim”
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Effects of Domestic Violence Profound effects on neurodevelopment Earlier exposure = worse outcomes
Emotional / Developmental / Academic / Behavioral / Physical problems AND potentially limited access to resources (medical care, mental health care, developmental support, academic support)
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Emotional problems and CEVDepressionAnxietyPTSTADHD
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Attachment system theory of development
04/20/23
Normal development is absolutely dependent on a bond with a loving caregiver
Affect regulation may be the most essential aspect of a child’s development
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Developmental problems and CEVLanguage (pre-verbal)Social / Emotional
Abnormal affect regulation Aggressive, separation issuesDevelopmentally appropriate symptoms
Motor Hyperarousable, withdrawn
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Behavioral problems and CEVDevelopmentally appropriate
manifestationsInfantToddlerElementary schoolAdolescent
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Physical IllnessAsthmaDiarrheaCariesFailure to thriveACE study
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Children Exposed to Violence are:Children with predictable, increased health
care needs
And should have…
Have access to a medical home to meet those needs
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Opportunity Pediatricians in ideal position to identify DV
/ CEV
High risk time for women & frequent visits to MD
Some women don’t seek care for self but do for children
Women DO disclose when asked
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American Academy of PediatricsAAP Committee on Child Abuse and Neglect
(1998) Policy Statement: The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women
“the abuse of women is a pediatric issue”“intervening on behalf of battered women
is an active form of child abuse prevention”“pediatricians are in a position to recognize
abused women in pediatric settings”“questions about DV should become part of
anticipatory guidance”
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AAP recommendsNeed residency and CME education & trainingPediatricians should attempt to recognize
evidence of family or intimate partner violence in the office setting
Pediatricians should intervene in a sensitive and skillful manner that maximizes the safety of women and children victims
Pediatricians should support local and national multidisciplinary efforts to recognize, treat and prevent family and intimate partner violence
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Fewer than 10% pediatricians routinely screen for DV
Barriers:
Education / Training
Time
Perception
Sense of powerlessness
Language / cultural sensitivity
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DV screening practiceVaries : written forms, as part of
safety/environmental screen Recommendations:
All women in pediatric settings should be screened for DV
Should not screen when partner in the room
Women do disclose DV when asked by a skilled provider in face to face
Insufficient evidence to recommend specific screening
practice
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Screening for DVAs part of child anticipatory guidance
Introductory statementDirect vs. indirect questionsInclude questions to adolescents and older
childrenAsk with children in room? (probably)
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Disclosures of DV: Physician’s Role First assess safety of mother & children Articulate concern over woman and
children’s safety
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Disclosures of DV: Physician’s RoleConnect any concerns over child to DV
(behavior, academic, emotional)
Offer information about resources and help – culturally and linguistically appropriate
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Disclosures of DV: Physician’s RoleDV shelter / support group / DV advocates
or hotlines
Offer to create a safety plan & schedule follow up appointment
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